1. Name of employer |
2. Workplace and address of workplace |
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3. Nature of business |
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4. Branch or department and exact place where accident occurred |
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5. Injured person's— |
(i) Surname |
(ii) Other names |
(iii) Address |
(iv) Sex |
(v) Age at last birthday |
(vi) Precise occupation |
6. Date and hour of accident |
7. Time injured person commenced work |
8. Nature of accident |
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If caused by machinery– |
(a) give name of machine and part causing accident |
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(b) state whether machine was moved by mechanical power at the time of the accident 9. Extent of disablement |
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9. Extent of disablement |
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10. Date disablement ceased |
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Date: |
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Signature of Employer |